Cataract Surgery - What to Expect (post 2 of 3) - Day of Surgery

Continuing my series of posts covering what to expect around the time of cataract surgery: today I will describe what I tell my patients to expect the day of surgery. Remember, this is what I tell my patients to expect - other surgeons will differ in what they tell their patients to expect depending on technique and preferences.

Day of Surgery:

1) When you arrive at the surgery center there will be some minimal additional paperwork to fill out.

2) You will change out of your clothing into a hospital gown (note: some surgery centers do not require this).

3) A mark will be made on your forehead indicating which eye is to have cataract surgery. This may be done in the "pre-op" area or in the operating room depending on which surgery center is used.

4) During the time you are in the surgery center you may be asked multiple times “what eye are you having surgery on?” This is not because the staff don’t know but because they check and double check that we are operating on the correct eye. This is for your protection.

5) Multiple drops will be placed in your eye multiple times. Although the drops you use at home must be spaced at least five minutes apart, the drops in the hospital will be given to you one right after the other. This is OK.

6) It may take 45 minutes to two hours for your eye to dilate enough to safely perform surgery. The doctor will check your pupil once you are in the operating room. Do not worry about the dilation - if needed there are techniques your doctor can use during surgery to sufficiently dilate your pupil.

7) An IV will be placed in your arm either in the pre-operative holding area or in the operating room. Once in the operating room the anesthesiologist will give you something through the IV to relax you. One of the effects of this medication is short-term amnesia. So, if you are having your second eye done, don’t be surprised if you don’t remember all of these things being done when you had your first cataract surgery. This is a very common feeling.

8 ) A blood pressure cuff will be placed on your other arm. This is necessary for monitoring this critical vital sign. Periodically this will inflate and give you a sense of pressure. Just relax and the pressure will go away.

9) Some doctors (myself included) feel that music works both to relax you and assist with the rhythm of surgery. If you have a particular type of music you would like to be played during the surgery, let your surgeon know. Note: not all surgeons accept requests, but I do (my iPod has over 9,000 songs so I can honor almost any request except country music - closest I have on my iPod is Johnny Cash, but I'll even listen to country music if you bring the CD).

10) During the actual surgery you will hear buzzing and bells. There may be a sense of pressure in the eye and you may feel fluid running down the side of your face. This is all normal.

11) You should not feel pain during the surgery (but you will feel pressure and sometimes a sense of "tugging"). If you do feel pain or discomfort, let your surgeon know and he will give you additional anesthetic.

12) You will be in the operating room for about 45 minutes to an hour. About half of this time is spent preparing for the actual surgery.

13) After surgery a shield will be placed over your surgery eye. you will then be transferred to a recovery area for and hour or so while the nurses check your vitals and confirm that you have recovered from the anesthetic.

14) The entire process from the time you arrive to the time you leave the hospital can take from three to five hours.

Afternoon and Evening of surgery:

You may have the sense that there is something in your eye like a grain of sand. This is normal and will be relieved by using the drops that you have been instructed to use. If needed, you may take Tylenol for relief. You should not have significant pain. If you do, call your surgeon's office as soon as possible.

Note: find out who will be taking call for your surgeon. Will it be the surgeon or another ophthalmologist or optometrist? Will you be able to get through 24 hours a day, seven days a week? Or, will you be forced to go to the emergency room after hours if there is a problem? Practices vary, but I take my own call except for every third weekend when my partner, Dr. Richard Kratz, takes call for me. Even then, he can get in touch with me as I carry my cell phone everywhere I go (I will even give my personal cell phone number to my patients who have had cataract surgery - though the fastest way to get in touch with me is actually through my answering service which picks up the phone whenever my office is closed - no answering machine or voicemail here).

Next post: what to expect after surgery...

© 2009 David Richardson, MD

Cataract Surgery - What to Expect (post 1 of 3) - Before Surgery

Over the course of this blog I will try to address all of the common questions I get asked by my patients. Many of these questions have to do with expectations. The next few posts will be about the mundane activities that surround cataract surgery: the stuff you can do, the stuff you should do, and the stuff you should not do.

Note: these posts will reflect my personal preferences. Other surgeons will have their own set of expectations. Each surgeon creates a set of guidelines based on his or her experience, training, techniques, and understanding of the literature. Additionally, I will modify these guidelines based on the needs or health of an individual patient.

So, assuming you have already chosen a surgeon and he or she has confirmed that you have a cataract and you would benefit from cataract surgery, what can you expect Prior to Cataract Surgery?

If you are a contact lens wearer you will need to stop wearing the lens in the eye that will have surgery for at least three weeks prior to surgery. You may need to return to the office multiple times to have your corneal curvature measured prior to surgery.

You will need to coordinate pre-operative medical clearance from your internist or family physician. This may include blood testing, an EKG, and a physical exam. This should be done at least two weeks (but not more than a month) prior to surgery.

You will need to come into the office for additional testing of the eye and to complete the necessary paperwork prior to surgery. Please make sure to bring your consent and filled out questionnaire with you. Expect to be in our office for two to three hours.

Expect a call from us about two to three days prior to surgery to let you know what time you need to arrive at the surgery center.

You will be using drops in the eye that will be operated on beginning three or four days prior to surgery. These drops function to protect the eye from infection and inflammation. We may have samples of some of the drops, but you will have to go to the pharmacy to pick up the others.

You can eat the night before surgery. After midnight, however, you should not eat or drink anything.

Next post: What to Expect the Day of Surgery

© 2009 David Richardson, MD

Why Cataract Surgery Might Not Be a "Piece of Cake" with Diabetes

While it is true that for most people cataract surgery is a "piece of cake," for surgery to go well it helps to have an otherwise healthy eye. If someone has any eye disease in addition to the cataract this will increase the risk that the final vision will be limited after surgery.

Unfortunately, the general experience of most people who have had cataract surgery does not apply when there is a history of diabetic retinopathy. People with otherwise healthy eyes might note that their vision was better before they even left the operating room. However, most of these people do not have diabetic retinopathy (for more on diabetic retinopathy visit my practice website and search for "diabetic retinopathy" - a list of articles and educational animations will be visible).

A history of diabetic retinopathy increases the risk of surgery. Eyes with a history of retinopathy are at higher risk of macular edema (swelling of the retina), and infection. Treating these conditions can be challenging.

Additionally, decreased night vision is often a result of the laser treatment for proliferative retinopathy (that's still better than the alternative of no treatment - loss of central and overall vision). Cataract surgery may help by allowing more light into the eye, but it will not completely improve it - there will still be some permanent limitation of night vision.

The most important thing someone with Diabetes can do to limit these additional risks of cataract surgery is to maintain good control of the blood sugar.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 9 of 9)

All right. Here we are. The final installment. All that's left now is to 'close' and double-check:

The incisions were then hydrated...

One method of closing the incision is to hydrate' it. Essentially, a sterile salt solution is injected into the cornea. This results in a local swelling around the incision forcing the incision closed. Often this acts as a substitute for suturing the incision. The problem is that we really don't know how long this swelling lasts. Will it keep the incision closed long enough to protect the eye from infection? For this reason I will often add a suture (see last post).

...and the anterior chamber was formed to physiologic pressure (confirmed by intraoperative tonometry) at which pressure the incisions were checked and felt to be watertight and of good integrity.

Basically, sterile saline is injected into the eye through the paracentesis (small 1mm incision) to bring the pressure in the eye back up to a 'normal' pressure. The incisions are then checked for leaks.

The lid speculum and drapes were then removed followed by placement of Vigamox drops in the fornices on the left.

Remember the bent-paperclip-like device used to keep the eye open? We don't need that anymore as the surgery is over. As a final step to protect from infection a drop of antibiotic is placed on the surface of the eye. Some surgeons inject an antibiotic into the eye at the end of surgery. To date there is no agreement in the US as to which provides more protection. There is a recently published European study that supports using an injection. However, the antibiotic used in the European study is not readily available for intraocular use in the USA. Therefore, most North American surgeons feel the risks of using a 'compounded' antibiotic (made by hand) out weights the potential protection it might provide. As mentioned in my last post, I have not had an episode of acute endophthalmitis in over 2,000 cases of cataract surgery using topical, not intraocular antibiotics. As this rate is similar to that experienced with the European method there does not seem to be a convincing reason to change. Again, using the wisdom of my father, 'If it's not broke, don't fix it.'

A shield was then placed over the left eye which the patient was instructed to keep on the eye except during placement of Nevanac, Vigamox, Omnipred 1% drops which she is to use including the day of surgery.

With topical anesthetic there is no need to patch the eye. A shield with little holes in it is sufficient to protect the eye from rubbing when the patient is sleeping. Additionally a shield is easier to take on and off than a patch. This is important in order to get the antibiotic and anti-inflammatory protection of the prescription drops.

She was instructed to avoid any heavy exertion...

Basically, I tell my patients not to pick up anything over 20 pounds, avoid swimming, gardening, high-impact aerobic activities, and "jerking" activities such as roller coaster riding, bungee jumping, skydiving, and the like. Most standard daily activities are just fine.

...and is to follow up in my office the day after surgery.

It is also acceptable to follow-up the day of surgery.

She tolerated the procedure well.

This is an understatement. Most people find cataract surgery to be a painless procedure and look forward to having surgery on their second eye shortly after their first eye has healed from surgery.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 8 of 9)

We're almost done. Believe it or not, however, these last steps can take up almost a third of the total time of surgery:

A single 10-0 Vicryl suture was then placed in the temporal corneal incision and the knot was buried in the corneal stroma.

These sutures are incredibly thin (about as thick as a strand of blond baby hair), difficult to work with (ever tried tying a knot of thin hair?), and expensive (about $15 per suture). Thus, suturing the incision is skipped by many surgeons.

No doubt you've seen advertisements for 'no-stitch' cataract surgery. It's sexy not to place a suture. And, it probably isn't necessary every time. If I am convinced beyond a doubt that the incision is watertight without the need for a suture then I won't place one either.

There are many reasons given for not placing a suture as it (1) may result in irritation; (2) can result in surface bleeding aka a 'sub-conjunctival hemorrhage;' (3) might have to be removed in the office. Certainly no surgeon wants his or her patients to have a beet-red eye after surgery because a suture was placed. And, a sub-conjunctival hemorrhage can look awful: 'what happened to your eye!' is another phrase surgeons don't want their patients to hear (it makes for bad advertising).

Additionally, as mentioned above, suturing is time consuming and expensive. Placing a suture can add five minutes to the time of surgery. This may not sound like much, but consider this: my average cataract surgery without placing a suture lasts 12-14 minutes. By placing a suture I have just increased my surgery time by almost 40%. Believe it or not, with the downward pressure on cataract surgery reimbursement (it is now about 1/10th of what it was in the 1970s) the only way for a surgeon and surgery center to make ends meet is to be efficient.

I like performing surgery and insurance companies know that most cataract surgeons would do this as a hobby. Thus, as long as I am not losing money on my surgery I'll keep doing it. And, as long as my surgery center allows, I'll keep placing a suture when I think it is needed. Why? Because placing a suture may decrease the risk of infection. I mentioned earlier that infection is one of the few things that can result in a loss of vision (or even blindness). If I can reduce the risk of infection from 1 in 500 to 1 in 1,000 or 2,000 then I will.

To date I have performed over 2,000 cataract surgeries without a single case of acute endophthalmitis (early infection of the eye). Most published studies on endophthalmitis report rates of 1 in 500 to 1 in 1,000. I believe part of the reason my patients have avoided this complication is my meticulous attention to incision closure and use of a suture when I feel it would benefit the integrity of the incision.

One more post to go...

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 7 of 9)

Continuing my series on what happens during cataract surgery, we have so far removed the cataract, but still have to place the new lens in the eye.

Provisc was then injected into the anterior chamber and capsular bag...

After phacoemulsification of the cataract and aspiration of the cortex, there is little remaining viscoelastic. In order to safely place the new intraocular lens (IOL) in the eye this gel must be replaced. This step also functions to open up the capsular bag and make it easier to position the IOL inside the bag. As much as possible we try to leave things as they were. What better place for the new lens than where the old lens (cataract) was: in the bag?

...following which the lens was inspected for proper power and good integrity.

I personally check the model and strength of the IOL before surgery and just before implantation in the eye. Although not all surgeons personally do this, I feel that this is something I should not delegate to someone else. Which IOL is placed in the eye determines the final vision after surgery. Pretty important step, wouldn't you agree?

The lens was placed in the insertion device which was used to insert the lens through the temporal incision,...

Not all lenses have to be placed in the eye using an inserter. Most lenses can also be folded. However, something must be done to the IOL in order to get it through the incision. Remember that the incision is only 2.2-3.6mm wide. Most IOLs have optics (round lenses) that are 5.5-6.0mm in diameter. Thus, they must be rolled, folded, or otherwise deformed in order to fit them through the corneal incision. Because they must be flexible, most modern IOLs are made of malleable materials such as silicon or acrylic.

...guiding the leading haptic into the capsular bag. The trailing haptic was positioned in the capsular bag using a lens manipulator.

The 'haptics' are flexible loops that stick out from the optic. These act to hold the lens in place and center it in the bag.

The remaining viscoelastic was then removed using automated irrigation and aspiration, taking care that no residual viscoelastic was trapped behind the optic.

Now that the cataract has been removed and the new lens is in the eye it is time to remove the protective gel. If it is left in the eye it will clog up the drainage system resulting in a high intraocular pressure after surgery. Many times, even with diligent removal of the viscoelastic material the pressure will still 'spike' up in the first 24 hours after surgery. However, this is often easily controlled with drops or by letting some of the fluid out of the eye through the paracentesis created at the beginning of the surgery.

Because the more advanced viscoelastics (which are thought to be more corneal protective) are more likely to remain in the eye after surgery I will go 'behind the lens' in order to remove as much as I can. Many surgeons choose not to take this extra step because it is risky without proper technique and difficult to do without a bi-manual irrigation and aspiration setup.

We are almost done. Next post: placing the suture.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 6 of 9)

Finally, it is time to remove the cataract:

Hydrodissection and hydrodelineation were then completed with a visible fluid wave and good nuclear mobility noted.

'Hydrodissection' is a technique used to free the cataract from its attachments to the capsular bag. Without freeing the lens, all surgical forces that act on the lens would be translated through the capsule to the zonules (the delicate cables that hold the lens in place). If these zonules are damaged during surgery then there will not be sufficient support to place a clear new lens in the eye.

During hydrodissection fluid is injected between the capsule and lens. This fluid travels around the lens creating a space between it and the capsule. If this step is not completed the remaining steps of catarct removal are more difficult and dangerous to perform.

Hydrodelineation is very similar to hydrodissetion except the layers separated are those of the lens nucleus (hard, central part of the cataract) and epi-nucleus (softer outer part of the cataract). This step does not have to be performed unless the surgeon uses an advanced technique call 'phaco-chop' (more on that next).

Phacoemulsification of the nucleus was then completed using a horizontal chop phacoemulsification technique requiring 0.6 minutes of phacoemulsification at 24% power.

Phacoemulsification is the ultrasound technology currently used by the majority of US surgeons. Essentially, a hollow tip vibrates at an extremely high frequency (faster than the speed of sound) breaking up the cataract into small pieces. These fragments are then vacuumed through the central opening of the tip and out of the eye. Other methods of breaking up the cataract do exist including laser and pulses of water. However, neither of these has really caught on in the US as the ultrasound works so well for most types of cataracts.

There is, however, a downside to ultrasound. If the tip of the ultrasound handpiece touches the capsule, the bag will tear allowing vitreous (the gel behind the capsular bag) to come forward. This is the main thing all cataract surgeons try to avoid as it often significantly complicates the surgery. Additionally, as discussed earlier, the ultrasound energy is not only absorbed by the cataract, but also by the cornea resulting in swelling. An advanced technique such as phaco-chop can reduce the total amount of ultrasound time used (compared to older and more basic techniques such as 'divide and conquer') and thus limit the amount of corneal edema.

The remaining cortex was then removed using bimanual automated irrigation and aspiration.

The cortex is that part of the catarct still adherent to the capsular bag. It has a stringy, tenacious character to it and is usually still present even with hydrodissection. It must be removed or the bag will not be optically clear resulting in blurred vision and inflammation. However, the capsule is very delicate an tears with any significant traction on it. To get an idea of what this is like lay out some cheap plastic wrap (the stuff you use to cover leftovers before you put them in the refrigerator) and stick some painter's tape on it. Now try to remove the tape without stretching or tearing the plastic wrap.

As you can imagine, this is another step in cataract surgery which has a high risk of 'capsular rupture,' resulting in 'vitreous loss,' or tearing of the capsule allowing the vitreous gel to come forward.

In order to decrease this risk I use a technique called 'bi-manual' irrigation and aspiration. This requires the simultaneous use of two instruments (rather than one) allowing me to obtain better control in the eye. Not every surgeon, however, uses the bi-manual technique as it requires (1) expensive handpieces that many surgery centers will not pay for (I own my bi-manual handpieces); (2) phacoemulsification equipment with excellent fluidics (a topic that would require its own post); (3) is technically more challenging to perform; (4) takes longer to complete than with 'co-axial' or one-handed irrigation and aspiration.

Next post: placing the new lens into the eye

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 5 of 9)

We are done preparing. Time to get to work:

The microscope was moved back into position...

Cataract surgery is microsurgery. Without a microscope it would not be possible to complete the steps to follow.

...and a paracentesis was created at the one and five o'clock positions...

A 'paracentesis' is a small incision (usually 1.0mm wide) in the cornea that allows the surgeon to place instruments or inject fluids into the eye (more on that next). In general when discussing orientation during surgery the eye is compared to a clock face with 12:00 the uppermost portion of the cornea (near the upper eyelid or brow) and 6:00 being the lowermost portion (near the lower eyelid or feet).

...through which 0.14 cc of Epi-Shugarcaine was injected into the anterior chamber.

'Epi-Shugarcaine' is a sterile solution of anesthetic and dilating medications developed by the late Dr. Joel Shugar. Not all surgeons use this solution. However, it can result in better anesthesia and dilation. I do not use it in all cataract surgeries but if a patient is on Flomax or has a small pupil I will instill Epi-Shugarcaine.

The 'anterior chamber' is a clinical term for the space between the iris (the colored part of the eye) and the posterior (backside of the) cornea (the clear front part of the eye on which a contact lens sits).

Viscoat was then injected into the anterior chamber firming up the globe.

Viscoat and Provisc are just two of many brands of viscoelastic. A 'viscoelastic' material, aka 'viscosurgical device' is a gel-like material that is placed in the eye in order to (1) create and maintain space to work-in, (2) protect the corneal endothelium. The corneal endothelium is made up of cells that pump fluid out of the cornea (keeping it clear). When these cells absorb the phacoemulsification energy (described in a later post) it 'shocks' them resulting in 'corneal edema' or a thickening of the cornea. Although usually self-limited, if this edema does not go away the vision would be blurred and a corneal transplant might be necessary. Thus, you can see why we would want to use something to protect the corneal endothelium.

A clear cornea temporal incision was then created with a metal keratome...

In order to remove the cataract and later place a new lens in the eye an incision must be made in the cornea. Currently there is no way around this. Thus, cataract surgery requires an incision. That being said, the incision is usually very small - on the range of 2.2-3.5mm wide.

This incision can either be made with a very sharp metal or diamond blade. Either one would make a standard razor blade appear dull by comparison. Because these blades must be manufactured to very exacting specifications they are quite expensive. A disposable metal blade runs anywhere from $35-70 per knife. Diamond blades, on the other hand, can be used hundreds of times before needing to be repaired or replaced. However, they are exceedingly expensive ($1,100-4,000) and are easily dulled or damaged.

...following which a continuous curvilinear capsulorrhexis was created using a bent needle cystatome on a Provisc syringe followed by capsulorrhexis forceps.

This is considered by many surgeons to be the most challenging element of the surgery. In order to get to the cataract an opening must first be made in the 'capsule' a delicate film-like material that holds the lens in place. This material is very thin (measured in microns, or millionths of a meter) and transparent. It is held in place by cables called 'zonules' that stretch it out over the surface of the lens.

Ideally, the surgeon wants to make a circular, or 'curvilinear' opening in the capsule. However, as you can imagine, tearing an opening in a thin, clear material on stretch is not a task for the faint of heart (considering that if the tear extends beyond the edge of the lens the rest of the cataract surgery becomes challenging, at best). There are two main ways of doing this: with a bent needle cystatome or with forceps. I use both. My father is a mechanic and taught me to use the best tool for the task at hand. As such, I find that the cystatome works best to start the capsulorrhexis and the forceps give me the most control over the shape of the opening.

Next post: getting to the actual cataract removal (finally)

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 4 of 9)

Today we continue our line-by-line evaluation of a typical cataract surgery operative report:

The patient was transported to the operating room in a supine position on a Stryker gurney.

This just means that the person about to have cataract surgery is lying face-up.

Once in the operating room, Tetracaine 0.5% drops were placed in the left eye following which Xylocaine 2% jelly was placed in the fornices on the left.

There are many ways to anesthetize the eye. Some doctors give an injection behind or beside the eye. However, this has risks associated with it which include perforating the eye (rare, but more likely in someone who is very nearsighted), bleeding, damage to the optic nerve, etc. For this reason, I prefer a 'topical' anesthetic. Anesthetic drops are placed on the eye for immediate anesthesia following which a gel is placed between the eyelids and eye in order to obtain a longer-lasting effect. The drops and gel do sting for a few seconds after they are placed in the eye, but there should not be any pain during the cataract surgery.

The microscope was moved into position and the patient was asked to look at the microscope light which she was able to do without difficulty.

Under topical anesthetic, movement of the eye is possible (indeed, preferred). This can be used to my advantage as a surgeon to direct the patient to look in a certain direction. However, if the patient cannot tolerate the bright microscope light then it might be best to give a retrobulbar or peribulbar injection of anesthetic (mentioned above). The benefits of giving an injection are that the anesthetic lasts longer and the eye is 'frozen' (meaning it cannot move during the surgery).

The microscope was moved out of position and the patient was prepped and draped in the standard sterile fashion using a povidone-iodine solution over the left face and lashes and a Betadine 5% ophthalmic solution in the fornices followed by a sterile saline rinse.

Prior to surgery the area around the eye must be cleaned, or 'prepped' using a Betadine solution to kill any bacteria on the skin (this helps to prevent infection). A dilute Betadine solution is also used to kill bacteria on the surface of the eye after which it is rinsed out using a salt solution or sterile water.

Steri-Strips were used to drape the lashes out of the operative field, following which Tegaderm was placed over the left face through which a lid speculum was placed.

One of the most commonly asked questions I hear is 'How will I keep my eyes open during surgery?' This is the answer to that. A sticky drape acts like scotch tape to keep the lashes away from the eye following which a device that looks like a bent paperclip is used to keep the eyelids open.

Now we are almost ready for surgery. In the next post we will actually get down to the business of surgery.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 3 of 9)

OK, let's begin. Following is the first paragraph of a typical cataract surgery operative report.

Preoperatively, Nevanac, Vigamox, Omnipred 1% drops were prescribed or given to the patient to use in the left eye four times a day beginning four days prior to surgery.

Before cataract surgery many surgeons will have the patient start eyedrops to prepare the eye for surgery. These drops perform the following functions:

An anti-inflammatory

Anti-inflammotory drops generally are split into two categories: (1) steroids or (2) Non-Steroidal Anti-Inflammatory Drugs aka NSAIDs. There is some evidence that beginning drops a few days prior to surgery can reduce the inflammation associated with surgery. The results of these studies are suggestive but not conclusive so not all surgeons begin anti-inflammatory drops prior to surgery.

An antibiotic to protect from infection

Infection is one of the few complications of surgery that can lead to loss of vision or blindness. Therefore it is worth taking every precaution to avoid it. By starting antibiotics prior to surgery, the bacteria living on the surface of the eye and eyelashes can be reduced. Additionally, the antibiotic builds up in the corneal tissue resulting in a depot of antibiotic that is slowly released into the eye after surgery.

The brand of the drops each surgeon uses may differ, but most surgeons order at least one drop from each of the above categories.

On the morning of surgery, the following drops were placed in the patient's left eye every 10-15 minutes x4 beginning approximately one hour prior to surgery: Mydriacyl 1%, Phenylephrine 2.5%, Vigamox, Nevanac.

Mydriacyl and Phenylephrine are dilating drops. These are used to enlarge the pupil so that your surgeon can get good visualization of the cataract prior to removal. Again, the brand of dilating drops and method of instillation may differ but dilation is necessary for safe and effective surgery

Next post we will be looking at the following section of the operative report:

The patient was transported to the operating room in a supine position on a Stryker gurney. Once in the operating room, Tetracaine 0.5% drops were placed in the left eye following which Xylocaine 2% jelly was placed in the fornices on the left. The microscope was moved into position and the patient was asked to look at the microscope light which she was able to do without difficulty. The microscope was moved out of position and the patient was prepped and draped in the standard sterile fashion using a povidone-iodine solution over the left face and lashes and a Betadine 5% ophthalmic solution in the fornices followed by a sterile saline rinse. Steri-Strips were used to drape the lashes out of the operative field, following which Tegaderm was placed over the left face through which a lid speculum was placed.

So then, How is Cataract Surgery done? (post 1 of 9)

There are so many incorrect beliefs about how cataract surgery is done that I spend a fair amount of my time with patients simply re-educating them about cataract surgery as well as what results they can realistically expect after surgery (for example: most people will still need bifocals or readers after surgery with a standard lens implant).

There are plenty of explanations about how surgery is performed (and even a few descriptive videos or animations available online). However, these are all simplifications of the actual procedure. For anyone interested in more detail there are very few resources available to the general public. Fortunately, there is a detailed description of every cataract surgery performed in the USA. This description, known as the operative report (or 'op report') is generated by the surgeon after each case and becomes part of the medical record.

Unfortunately for those interested in reviewing these detailed reports, they are not available to the public as they are 'protected health information' (or PHI) that cannot be released except to a very limited number of approved entities (such as the insurance company) and individuals (such as the actual patient and his or her health care providers). Fortunately for the readers of my blog, I have created a draft of my standard operative report without any of the usual identifying information. Over the next two weeks I will publish this report as well as a line-by-line explanation of the terminology used in the report.

I believe this will be the only such example of an actual operative report template available online. Even if there are other PHI-stripped copies floating around on the net, the explanations I will provide over the next few posts are truly an exclusive inside look into the workings of a typical cataract surgery.

Next post: The operative report

So then, How is Cataract Surgery done? (post 2 of 9)

As promised, I have included a typical operative report in this post (it has been stripped of all identifying information). For anyone outside of the field of ophthalmology reading this will most likely be as clear as mud. Don't worry, over the next few posts I will clarify this post in excruciating detail. When you are done reading this series of posts, you'll probably know more about how cataract surgery is done than your own internist.

Procedure in detail:

Preoperatively, Nevanac, Vigamox, Omnipred 1% drops were prescribed or given to the patient to use in the left eye four times a day beginning four days prior to surgery. On the morning of surgery, the following drops were placed in the patient's left eye every 10-15 minutes x4 beginning approximately one hour prior to surgery: Mydriacyl 1%, Phenylephrine 2.5%, Vigamox, Nevanac.

The patient was transported to the operating room in a supine position on a Stryker gurney. Once in the operating room, Tetracaine 0.5% drops were placed in the left eye following which Xylocaine 2% jelly was placed in the fornices on the left. The microscope was moved into position and the patient was asked to look at the microscope light which she was able to do without difficulty. The microscope was moved out of position and the patient was prepped and draped in the standard sterile fashion using a povidone-iodine solution over the left face and lashes and a Betadine 5% ophthalmic solution in the fornices followed by a sterile saline rinse. Steri-Strips were used to drape the lashes out of the operative field, following which Tegaderm was placed over the left face through which a lid speculum was placed.

The microscope was moved back into position and a paracentesis was created at the one and five o'clock positions through which 0.3 cc of Epi-Shugarcaine was injected into the anterior chamber. Viscoat was then injected into the anterior chamber firming up the globe. A clear cornea temporal incision was then created with a metal keratome following which a continuous curvilinear capsulorrhexis was created using a bent needle cystatome on a Provisc syringe followed by capsulorrhexis forceps. Hydrodissection and hydrodelineation were then completed with a visible fluid wave and good nuclear mobility noted. Phacoemulsification of the nucleus was then completed using a horizontal chop phacoemulsification technique requiring 0.7 minutes of phacoemulsification at 19% power. The remaining cortex was then removed using bimanual automated irrigation and aspiration. Provisc was then injected into the anterior chamber and capsular bag following which the lens was inspected for proper power and good integrity. The lens was placed in the insertion device which was used to insert the lens through the temporal incision, guiding the leading haptic into the capsular bag. The trailing haptic was positioned in the capsular bag using a lens manipulator. The remaining viscoelastic was then removed using automated irrigation and aspiration, taking care that no residual viscoelastic was trapped behind the optic. A single 10-0 Vicryl suture was then placed in the temporal corneal incision and the knot was buried in the corneal stroma.

The incisions were then hydrated and the anterior chamber was formed to physiologic pressure (confirmed by intraoperative tonometry) at which pressure the incisions were checked and felt to be watertight and of good integrity. The lid speculum and drapes were then removed followed by placement of Vigamox drops in the fornices on the left. A shield was then placed over the left eye which the patient was instructed to keep on the eye except during placement of Nevanac, Vigamox, Omnipred 1% drops which she is to use including the day of surgery. She was instructed to avoid any heavy exertion and is to follow up in my office the day after surgery. She tolerated the procedure well.

How your Eye Doctor can tell if you have Dry Eyes

As discussed in an earlier post, one of the most common symptoms of dry eye syndrome is tearing. Even with an explanation of how this occurs, many are unconvinced. How do you know that your doctor isn't just telling you this to give you pause while he slips out of the exam room and on to his next patient. "Ah, the old dry eye ruse:" tell the patient that having too much tear is really related to having too little tear and disappear through the door while the unsuspecting patient is mulling this over.

Well, as much as the demands of modern medicine do limit that amount of time doctors can spend with their patients (and, BTW, this really is not in the doctors control - topic for another post), the dry eye explanation is not a ruse. Dry eye syndrome is something that can often be objectively diagnosed at the slit lamp (aka biomicroscope) in the eye doctor's office. Following is a description of how an ophthalmologist would typically diagnose dry eye syndrome.

Assess Symptoms
As with most medical disorders, the diagnosis of dry eye syndrome is 80% listening to the patient. Following are the things I listen for:

What are the symptoms?

Tearing

Ocular irritation

Foreign Body Sensation (a sense that something is in the eye)

Red eye

Tired eyes

Flucturating vision with certain activities

When do the symptoms occur?

First thing in the morning

Later in the day

After extended periods of concentration

With reading

With computer use

With TV use

What medications are currently being used?

Blood pressure medications

Diuretics

Hormone replacement therapy

Allergy medications

Examine the Eye
Even with the best listening, the diagnosis must be confirmed by examining the eye. Following are the things I look for:

A decreased tear lake (a thin tear film over the cornea)

A decreased Tear Breakup Time (the tear film is not stable)

An irregular corneal surface

Dry patches on the corneal surface

Test the Tear Film
Sometimes special testing is required to diagnose dry eye syndrome. Following are some common tests for dry eye syndrome:

Schirmer's testing: evaluates how much tear is produced in five minutes

A decreased Tear Breakup Time (the tear film is not stable)

Lissamine Green staining: reveals devitalized corneal surface cells

Rose Bengal staining: also reveals devitalized corneal surface cells

Lactoferrin level test: a low level indicates dry eyes

Not all of the above examination or testing methods are necessary to diagnose dry eye syndrome. However, some combination of the above is used to provide a more objective assessment of the presence or absence of dry eye.

10 Essential Items Everyone Must Be Aware of Before Selecting An Eye Doctor

A lot of people consider their sight to be their most important sense. Yet, every day thousands of people have surgery on their eyes without having done any research on their eye surgeon. Who does your eye surgery is one of the most critical decisions you will make.

It doesn't take a large investment of time to choose your surgeon if you know how. The following listing of Ten Essential Things Everyone Must Be Aware of Before Selecting An Eye Surgeon will instruct you how. With this list you can decide on an excellent eye surgeon in less time than many people dedicate to selecting their next automobile.

1. Don't limit your selections to just those eye doctors in your insurance network.Despite what your insurance company's marketing brochures may indicate, the essential factor in deciding who is "in-network" is who is willing to sign that insurance contract. Presently there is no well-grounded method of scoring doctors and any insurance company that suggests their network of doctors is the most qualified is disingenuous at best.

2. Ask those you trustGood sources of information include your primary care physician, optometrist, and friends who have had eye surgery. Even better references include the operating room technicians and staff at your local hospital. They are often in the operating room with the cataract surgeon and recognize which surgeon is the most skilled. Nurses are frequently very helpful people and will often be disposed to respond to your question. The difficulty will be making it beyond the hospital's automated telephone maze and getting access to a live operating room nurse.

3. Research your eye surgeon's trainingWhere did your eye surgeon get her education? You may not know which training programs are the best, but it is simple enough to find their rankings once you know where your surgeon trained. Two objective resources are U.S. News & World Report's Annual rating of Medical Schoolsand Eye Hospitals

Don't get too caught up on the rating order - if your physician trained at a top 20 program he experienced superb training.

4. Research your eye surgeon's State LicensureYour physician must be licensed to practice medicine in his state. In addition to confirming licensure, many state license internet sites will also inform you if there is any history of corrective or legal action against your cataract surgeon. In California you can look up this data online at http://www.medbd.ca.gov/lookup.html

5. Confirm that your Eye Doctor is Board CertifiedBoard certification is a type of "seal of approval" for all doctors. In order to acquire certification an eye surgeon must successfully pass both a written and oral examination. In addition, younger eye surgeons must recertify every decade - a process that can take up to three years to complete. You can confirm that your ophthalmologist is board certified by checking the internet site: http://www.abop.org or http://www.abms.org

6. Look up your surgeon's Medical Practice SiteAssuming the above background check is favourable you can sometimes get useful information from your eye doctor's web site. Although some sites do provide educational materials, keep in mind that the website's essential goal is to market the practice. You won't see anything unfavorable about your doctor there, but it can confirm the constructive data you have already found and give you some insight into the ophthalmologist's background and medical practice philosophy.

7. Find out what others have gone through.Are testimonials available online (eye surgeon ranking internet sites or medical practice site)? Are testimonials accessible in your eye surgeon's reception area for your review? Will your cataract surgeon offer you the contact information of someone who had surgery that you can talk to?

Keep in mind that Federal privacy rules restrict the amount of information your cataract surgeon may be able to issue you regarding other patients who have had cataract surgery. Notwithstanding, it shouldn't be too onerous for your cataract surgeon to come up with a live person who would be willing to talk about the eye surgery experience with you.

8. Learn how many cataract surgeries your doctor has performed.There is a reason they call it the "practice of medicine." Just like a sports professional, an eye surgeon's skills improve with practice and experience. Every surgery differs in its "threshold" number (the number of surgeries necessary for the typical surgeon to become proficient). For cataract surgery I think this number is probably around 500.

If you are uneasy inquiring straightaway then take someone with you to the appointment to ask for you. This is a critical question. These are your eyes. You only have two. Get over your reluctance. Just ask.

9. Meet the Physician.The above research can give you an idea if your cataract surgeon is well-qualified to perform your surgery. Nevertheless, you cannot know if this is the ophthalmologist you want operating on your eyes until you meet with him. In addition to confirming his or her certifications, you need to be comfortable with this person.

Trust is a fundamental consideration that can't be sufficiently built up without encountering your cataract surgeon face-to-face.

10. At Long Last, get a second impression.Most people wouldn't buy an auto without test driving it and at least one other car. Why would you limit your choice of eye doctor because "he's on my insurance plan" before getting a sense of how comfortable you are with the choice your insurance has made for you? This is a very serious decision.

Unless you are totally at ease with your surgeon, get a second opinion.The most experienced doctors do not mind that you have or are going to get a second opinion. In fact, one quick test of your ophthalmologist's comfort with his or her own ability is to let him know that you would like a second opinion. If the ophthalmologist becomes defensive about this then you know the second opinion was a superb idea, after all.

In summary, there are many things you can easily do to affirm that you have made a good decision about who will perform your cataract surgery. Looking At the importance of your vision, you owe it to yourself to complete this inquiry before having cataract surgery.